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SWRCB, January 2006 <br />This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: VERIZON-MANTECA CO Date of Testing: 9/16/2010 <br />Facility Address: 430 W. CENTER STREET <br />Facility Contact: MASOOD CHOUDHURY Phone: (909)620-5962 <br />Date Local Agency Was Notified of Testing: 9/13/2010 <br />Name of Local Agency Inspector (ifpresent during testing): THUY TRAM <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: SUNWEST ENGINEERING INC, <br />Technician Conducting Test: TODD HANSEN <br />Credentials : CSLB Contractor [j ICC Service Tech.0 SWRCB Tank Tester❑ Other (Specify) <br />License Number(s): 8045710 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: HYDROSTATIC <br />Test Equipment Used: WATER <br />Identify Spill Bucket (by Tank <br />Number Stored Product etc. <br />1 DIESEL FUEL <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />Direct Bury <br />EContained in Sum <br />❑Direct Bury <br />[j Contained in Sum <br />[I Direct Bury <br />[]Contained in Sump <br />Direct Bury <br />Contained in Sum <br />_ <br />Bucket Diameter: <br />10.5" <br />Bucket Depth: <br />10.5" <br />Wait time between applying <br />vacuum/water and start of test: <br />15 min. <br />Test Start Time (Ti): <br />10:15AM <br />Initial Reading (Ri): <br />1.5" BELOW GRADE <br />Test End Time (TF): <br />11:15AM <br />Final Reading (RF): <br />1.5" BELOW GRADE <br />Test Duration (TF- TI): <br />60 MIN <br />Change in Reading (RF- RI): <br />0" <br />Pass/Fail Threshold or <br />Criteria: <br />0.000" <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) THE SPILL <br />BUCKET FAILED THE HYDROSTATIC TEST INITIALLY. I FOUND THE SPILL BUCKET GASKET WAS DAMAGED. I <br />REPLACED THE GASKET WITH A NEW ONE AND THE SPILL BUCKET PASSED THE HYDROSTATIC TEST. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: Date:9/16/10 <br />1 State laws and regulations do not current y require testing to be performed by a qualified contractor. However, local requirements <br />may be more stringent. <br />